Nursing Elites

1. A client with congestive heart failure taking digoxin reports nausea and refuses to eat breakfast. Which action should the nurse take first?

• A. Encourage the client to eat the toast on the breakfast tray.
• B. Administer an antiemetic.
• C. Inform the client's provider.
• D. Check the client's apical pulse.

Correct answer: D

Rationale: The correct action for the nurse to take first is to check the client's apical pulse. Nausea can be a sign of digoxin toxicity, and one of the early signs of digoxin toxicity is changes in the pulse rate. By checking the client's apical pulse, the nurse can assess if the digoxin level is too high. Encouraging the client to eat or administering an antiemetic may not address the underlying issue of digoxin toxicity. While informing the provider is important, assessing the client's condition through checking the apical pulse should be the immediate priority.

2. A nurse is preparing to administer furosemide 4 mg/kg/day PO divided into 2 equal doses daily to a toddler who weighs 22 lb. How many mg should the nurse administer per dose? (Round the answer to the nearest whole number)

• A. 20 mg
• B. 15 mg
• C. 10 mg
• D. 30 mg

Correct answer: A

Rationale: To calculate the dosage per dose, first, convert the toddler's weight from pounds to kilograms: 22 lb / 2.2 = 10 kg. Then, multiply the weight by the dosage: 4 mg × 10 kg = 40 mg/day. Since this total daily dose is divided into 2 equal doses, the nurse should administer 20 mg per dose. Therefore, the correct answer is 20 mg. Choice B (15 mg) is incorrect because it does not account for the correct weight conversion and dosage calculation. Choice C (10 mg) is incorrect as it only considers the weight conversion but doesn't multiply it by the dosage. Choice D (30 mg) is incorrect as it miscalculates the dosage by not dividing the total daily dose into 2 equal parts.

3. A nurse is administering subcutaneous heparin to a client who is at risk for deep vein thrombosis. Which of the following actions should the nurse take?

• A. Administer the medication into the client's abdomen.
• B. Inject the medication into a muscle.
• C. Massage the site after administering the medication.
• D. Use a 22-gauge needle to administer the medication.

Correct answer: A

Rationale: Heparin is best absorbed and less likely to cause hematomas when administered into subcutaneous tissue, specifically the abdomen, which is a common site for subcutaneous injections. Injecting heparin into a muscle (Choice B) is incorrect as it should be administered subcutaneously. Massaging the site after administering the medication (Choice C) is contraindicated as it can cause tissue damage or bruising. Using a 22-gauge needle (Choice D) is not recommended for subcutaneous injections of heparin; a smaller needle size such as 25-26 gauge is preferred for subcutaneous administration.

4. A nurse is preparing to administer an enteral tube feeding through an NG tube at 250 mL over 4 hr. The nurse should set the pump to deliver how many mL/hr? (Round the answer to the nearest whole number)

• A. 63 mL/hr
• B. 36 mL/hr
• C. 78 mL/hr
• D. 90 mL/hr

Correct answer: A

Rationale: To calculate the rate for the enteral tube feeding, divide the total volume by the total time: 250 mL / 4 hr = 62.5 ≈ 63 mL/hr. Therefore, the nurse should set the pump to deliver 63 mL/hr. Choices B, C, and D are incorrect as they do not match the correct calculation result. B is too low, C is too high, and D is also too high based on the correct calculation.

5. A client with ulcerative colitis has been prescribed sulfasalazine. The nurse should instruct the client to monitor for which of the following adverse effects of this medication?

• A. Jaundice
• B. Constipation
• C. Oral candidiasis
• D. Sedation

Correct answer: A

Rationale: The correct answer is A: Jaundice. Sulfasalazine can cause liver damage as a possible adverse effect, which can manifest as jaundice. Monitoring for jaundice is crucial to detect liver-related adverse effects early. Choices B, C, and D are incorrect. Constipation, oral candidiasis, and sedation are not typically associated with sulfasalazine use. Therefore, the nurse should focus on educating the client specifically about monitoring for jaundice.

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